PFD report

Trevor Coy BAILEY · Prevention of Future Deaths report

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Issued 20 Oct 2023•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to record relevant family medical history
    Part of recurring concern: Incomplete cardiovascular risk information for clinical assessment and investigationPart of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Failure to elicit smoking status and family history of ischaemic heart disease in the emergency department
    Part of recurring concern: Incomplete clinical history-taking
  3. Failure to elicit relevant family medical history
    Part of recurring concern: Incomplete cardiovascular risk information for clinical assessment and investigationPart of recurring concern: Incomplete clinical history-takingPart of recurring concern: Unreliable recording of patients' clinically relevant medical history
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.

    Stated by Church Lane SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023.
  2. Action

    Train staff to collect and accurately record family-history information in the clinical system.

    Stated by Church Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
  3. Action

    Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.

    Stated by Church Lane SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The established HEART-based chest pain pathway and cardiology governance were considered sufficient to determine appropriate rapid access chest pain referrals.

    Stated by London North West University Healthcare NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to record relevant family medical history

Wider context from the report

“1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012. However, this information was not on Mr Bailey’s medical record, it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████ ████████, on 19 or 27 April 2023. The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient. ”

Is this part of a recurring concern?

Yes — Incomplete cardiovascular risk information for clinical assessment and investigation; Incomplete, inaccurate or unavailable clinical and care records.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to elicit smoking status and family history of ischaemic heart disease in the emergency department

Wider context from the report

“However, it does not appear that these two pieces of information were elicited by those assessing Mr Bailey in the emergency department of Northwick Park Hospital. I heard evidence that, if they had been, he should have been referred to the rapid access chest pain clinic. Given the sequence of events, it seems unlikely that such a referral would have resulted in definitive treatment before Mr Bailey’s fatal myocardial infarction, but it could be a life saving referral for another patient in Mr Bailey’s position. ”

Is this part of a recurring concern?

Yes — Incomplete clinical history-taking.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to elicit relevant family medical history

Wider context from the report

“1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012. However, this information was not on Mr Bailey’s medical record, it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████ ████████, on 19 or 27 April 2023. The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient. ”

Is this part of a recurring concern?

Yes — Incomplete cardiovascular risk information for clinical assessment and investigation; Incomplete clinical history-taking; Unreliable recording of patients' clinically relevant medical history.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient time in the duty doctor system to deal with patients appropriately

Wider context from the report

“2. ████████ told me in the witness box that she had identified immediately after Mr Bailey’s death in May 2023 that the duty doctor system at Church Lane Surgery does not allow sufficient time to deal with patients appropriately. However, she has not progressed this issue in the five months since. ”

Is this part of a recurring concern?

Yes — Unreliable duty system arrangements for safe clinical coverage.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.

Verbatim wording from the response

“Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

Source location

Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Train staff to collect and accurately record family-history information in the clinical system.

Verbatim wording from the response

“Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

Source location

Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.

Verbatim wording from the response

“Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

Source location

Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Add three unbooked telephone slots and three face-to-face slots to each duty doctor’s shift.

Verbatim wording from the response

“2. Actions to re-structure the On-call system for the Duty doctor.”

Source location

Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit new family-history entries every 12 months to assess system progress.

Verbatim wording from the response

“Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

Source location

Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the NHS health-check template to record negative family history of ischaemic heart disease.

Verbatim wording from the response

“We have taken the following steps to update the family history of coronary heart disease (IHD).”

Source location

Response from Chuch Lane Surgery
Page 2 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The established HEART-based chest pain pathway and cardiology governance were considered sufficient to determine appropriate rapid access chest pain referrals.

Verbatim wording from the response

“As further evidence we do routinely satisfy our selves that even though this is a well used guideline we are still happy with it. In December 2022 our cardiology team attended the emergency department clinical governance meeting to present data from referrals. The data showed that patients with referrals with a low heart score did not go on to have investigations in the rapid access chest pain clinic and based on this data the cardiology team confirmed that a low heart score did not require a referral to the rapid access chest pain clinic.”

Source location

Response from London North West University Healthcare NHS Trust
Page 2 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Additional smoking and family-history information would not have triggered rapid access chest pain clinic referral under the HEART scoring system.

Verbatim wording from the response

“The point we would like to make is that even if he had not self discharged, based on the information given to the team at the time if the patient underwent a HEART score the patient would score 1.”

Source location

Response from London North West University Healthcare NHS Trust
Page 2 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.

Verbatim wording from the response

“It has been discovered that the patient's brother had a history of cardiovascular disease in 2006 and 2012, which was not disclosed during previous encounters in 2012, 2018, or recent visits. As a result, it is now clear that the patient had a family history of cardiovascular disease that was not reported in previous encounters. This information was not taken into account, and the patient was not prescribed any cardio protective medication due to the low cardiovascular risk score as per NICE guidelines.”

Source location

Response from Chuch Lane Surgery
Page 2 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The acute chest symptoms were appropriately investigated and safety-netted regardless of recorded cardiovascular risk factors.

Verbatim wording from the response

“On 19.4.23, during his telephone consultation, Mr. Bailey reported a history of chest pain/tightness intermittently for 2 weeks. If a person has a history of chest tightness, it is important to investigate the acute and high risk causes of the symptoms, regardless of whether they have any risk factors for ischaemic heart disease (IHD). This is because there may be a serious underlying cardiac or non-cardiac condition that needs urgent attention, such as pulmonary embolism, cardiac ischemia, aortic dissection or pericarditis,etc. Mr. Bailey was hence advised to go to the emergency department immediately on April 19, 2023.”

Source location

Response from Chuch Lane Surgery
Page 2 · response
Published 6 November 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Introduce and operate a separate Emergency Assessment Unit for low- and medium-risk emergency patients requiring timely assessment without monitoring.

    Stated by London North West University Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
  2. 2

    Review low-HEART-score chest pain referrals through clinical governance and confirm whether rapid access chest pain referral is required.

    Stated by London North West University Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
  3. 3

    Share the template issue with the primary care network, Borough Director and Local Medical Committee.

    Stated by Church Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
  4. 4

    Conduct and discuss a Significant Event Analysis at a practice meeting.

    Stated by Church Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce and operate a separate Emergency Assessment Unit for low- and medium-risk emergency patients requiring timely assessment without monitoring.

Verbatim wording from the response

“As part of our ongoing governance and improvement cycles, in November 2023 the Emergency department introduced a separate unit called Emergency Assessment Unit. The unit is designed to see the low and medium risk patients that do not need to be on a monitor. Trevor Bailey would have fit into this category. The patients in this unit are rapidly seen and assessed. The unit has improved the waiting time for these patients and has ensured that ECGs can be done in a timely manner. The outcome of the management of the patient would be the same in this unit as the HEART score would be the same.”

Source location

Response from London North West University Healthcare NHS Trust
Page 2 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review low-HEART-score chest pain referrals through clinical governance and confirm whether rapid access chest pain referral is required.

Verbatim wording from the response

“As further evidence we do routinely satisfy our selves that even though this is a well used guideline we are still happy with it. In December 2022 our cardiology team attended the emergency department clinical governance meeting to present data from referrals. The data showed that patients with referrals with a low heart score did not go on to have investigations in the rapid access chest pain clinic and based on this data the cardiology team confirmed that a low heart score did not require a referral to the rapid access chest pain clinic.”

Source location

Response from London North West University Healthcare NHS Trust
Page 2 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share the template issue with the primary care network, Borough Director and Local Medical Committee.

Verbatim wording from the response

“We have addressed the template issue with our PCN, Borough Director and the LMC, as this issue has raised concerns if a family history had been sought at all, during the health checks. We hope this will ensure that the information reaches all our area practices that use the same templates, so that they can take appropriate action and are not disadvantaged.”

Source location

Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct and discuss a Significant Event Analysis at a practice meeting.

Verbatim wording from the response

“Actions taken”

Source location

Response from Chuch Lane Surgery
Page 2 · response
Published 6 November 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026